The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

KINGSBROOK JEWISH MEDICAL CENTER 585 SCHENECTADY AVENUE BROOKLYN, NY 11203 Feb. 15, 2018
VIOLATION: INFECTION CONTROL Tag No: A0747
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Based on observation, document review and interview, the facility failed to implement the hospital's infection control program.
Specifically, the facility failed to:
(a) Prevent the cross contamination of equipment and supplies during cleaning.
(b) Perform hand hygiene between glove changes.
(c) Don appropriate Personal Protective Equipment (PPE).
(d) Move Operating Room (OR) equipment to allow mopping of all floor surfaces.
(e) Secure seven (7) Sharps Containers.
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This failure may place patients and staff at increased risk for the transmission of infections and communicable diseases.
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Findings include:
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See tag A749
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VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
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Based on observation, document review and interview, in ten (10) of 16 (sixteen) observations, the facility did not ensure that staff adhered to acceptable standards of Infection Control Practices. The facility's staff failed to:
(a) Prevent the cross contamination of equipment and supplies during cleaning.
(b) Perform hand hygiene between glove changes.
(c) Don appropriate Personal Protective Equipment (PPE).
(d) Move Operating Room (OR) equipment to allow mopping of all floor surfaces.
(e) Secure seven (7) Sharps Containers.

These lapses in Infection Control Practices places patients and staff at increased risk for facility acquired infections.

FINDINGS RELATED TO (a) INCLUDE:

(a1)
Observations of the facility's Minkin 4 (M4) Unit on 02/13/18 during a tour between 11:30AM and 12:30PM identified the following:

Staff D (Patient Care Technician) entered the Contact Isolation Room of two (2) Candida Auris (a multi- resistance type of yeast) positive patients. The staff member placed the glucometer on a disposable liner on Patient #6's bedside table next to the water pitcher and other medical supplies, then reached under her isolation gown, retrieved and scanned her badge, scanned the patient, and performed the glucose testing. After testing the patient, Staff D returned the contaminated glucometer to the bedside table, retrieved cleaning wipes from a dispenser with contaminated gloves, cleaned the top and sides of the meter without cleaning the bottom, then placed the meter in a plastic bag outside the patient's room. Staff D then exited the room without cleaning her badge. This was confirmed with Staff C (Nurse Manager).

During an interview with Staff C (Nurse Manager) at the time of the observations Staff C stated that the staff member (Staff D) should have scanned her badge outside the patient's room, placed a clean barrier on the table for the glucometer and supplies, removed the contaminated gloves after testing the patient, performed hand hygiene, donned clean gloves before retrieving cleaning wipes to clean the machine, cleaned all surfaces of the machine, cleaned her badge and performed hand hygiene prior to exiting the room.

The facility Policy and Procedure titled "Bedside Glucose-NOVA Stat Strip" last revised 12/01/2015, directed staff to "set up a 'clean space' away from the patient's bedside using a paper towel on a clean dry area. Place the glucometer and bottle of test strips on a paper towel."

The facility Policy and Procedure titled "Cleaning and Disinfection of the Nova Stat Strip Glucometer" last revised 12/04/15, contained the following statements: "to ensure proper disinfection, it is important to clean the meter (Step 1) prior to disinfecting the meter (Step 2) .... Wipe the external surface of the meter thoroughly with a fresh germicidal disinfecting bleach wipe. Discard the used wipe into trash can. Using a new, fresh germicidal bleach wipe, thoroughly wipe the surface of the meter (top, bottom, left and right sides)." The Policy however, lacked guidance directing the staff when to change gloves after glucose testing and prior to cleaning the machine.

(a2)
On 02/14/18 at 10:50AM, Staff Ee (Housekeeper) was observed cleaning the Contact Isolation Room of a Candida Auris patient. The staff member placed the garbage receptacle against the frame of the doorway to the patient's room, emptied the trash touching the garbage receptacle, retrieved a spray bottle and cleaning wipes from a dispenser on his cleaning cart contaminating the outside of the dispenser. After completion of the cleaning, the staff member returned the spray bottle to the cleaning cart without cleaning the outside of the bottle or cleaning wipe dispenser. He removed his PPE, performed hand hygiene, then exited the room touching the contaminated garbage receptacle and contaminated the cleaning cart.

This was observed in the presence of Staff Dd (Director of Environmental Services / EVS),
Staff B (Senior Director of Nursing / DON) and Staff C (Nurse Manager) who acknowledged the findings.

On 02/14/18 at 2:40PM Staff Ff (Housekeeper) was observed during a terminal cleaning (the thorough cleaning of a patient room following discharge in order to remove germs). of Room 432A. The staff member began cleaning the room wiping the surfaces of the patient's bedside table, bed and other equipment without performing high dusting (cleaning of all surfaces above shoulder height). The same staff member was also observed re-contaminating equipment already cleaned by placing them on surfaces that were dirty.

During interview of Staff Ff at the time of the observation, regarding if she should have performed high dusting prior to wiping the surfaces, Staff Ff stated: "I am supposed to, but I didn't see the duster on my cart".

This was observed in the presence of Staff B (Senior Director of Nursing / DON) who acknowledged that the staff member should have performed high dusting prior to wiping the surfaces.

On 02/15/18 at 9:30AM Staff Cc (Housekeeper) was observed during the terminal cleaning of Room 230. During wiping of the surfaces, the staff member failed to cover all surfaces of the cabinet, patient's bed and bedside table. The staff member did not clean the chair in the patient's room or move a garbage receptacle when mopping the floor.

This was observed in the presence of Staff Members Dd, B and Q (Director of Quality) who acknowledged the findings.

The facility Policy and Procedure titled "Terminal Cleaning of Rooms for Patients on Infection Control Precautions" last revised 01/30/18 contained the following statements: "High dust, beginning at the entranceway and working around the room in a circle ... disinfect all patient contact surfaces, including: call button, bedrails, ... head / footboard ... chairs .... Clean equipment and return supplies to cart or cleaning closet after use."

(a3)
On 02/14/18, between 10:30AM and 11:00AM, Staff G was observed in the facility's Operating Room. The observations of Staff G (Certified Nursing Assistant / CAN) identified the staff member performed cleaning in the incorrect order. Staff G had cleaned the OR table and placed a clean table drape onto the OR table. Staff G then performed cleaning of the OR lamp directly over the OR table after it had been cleaned and draped.

This was confirmed with Staff P (Senior Vice President of Peri-Operative Services) at the time of observation.

The facility Policy and Procedure titled "Cleaning and Sanitation", last revised 11/20/17 stated: "All horizontal surfaces of furniture and/or equipment will be damp cleaned with a disinfectant. This will be done between every surgical procedure by the OR personnel working from an area of least contamination to an area of greatest contamination." According to this Policy, the OR lamp should have been cleaned prior to the OR table.


FINDINGS RELATED TO (b) INCLUDE:

(b1)
On 02/13/18 at 11:45AM Staff D (Patient Care Technician) was observed removing her contaminated gloves after disinfecting the top of the PPE supply cart and without performing hand hygiene walked down the hall to retrieve patient supplies.

This was observed in the presence of Staff C (Nurse Manager) who acknowledged that the staff member (Staff D) should have performed hand hygiene after removing her contaminated gloves.

During observations on 02/14/18 at 2:40PM Staff Ff (Housekeeper) washed her hands, closed the faucet with wet hands, then retrieved paper towels and dried them. The same staff member was again observed during environmental cleaning removing her contaminated gloves and retrieving new gloves then donning them without performing hand hygiene,

This was confirmed with Staff Dd (Director of Environmental Services / EVS) at the time of the observation.

On 02/15/18 at 9:30AM Staff Cc (Housekeeper) was observed applying alcohol based hand rub then blowing on her hands to dry them. This was observed in the presence of Staff B (Senior Director of Nursing / DON), Staff Q (Director of Quality) and Staff Dd (Director of Environmental Services / EVS) who acknowledged the findings.

The facility Policy and Procedure titled "Administrative: Hand Hygiene Guidelines" last revised 07/28/2015, contained the following statements: "Healthcare personnel should wash their hands with plain or antimicrobial soap upon removal of gloves ... dry thoroughly with a paper towel ... use a paper towel to turn off the faucet .... Hand hygiene with Alcohol-Based hand rub: apply product to palm of one hand, rub hands together, rub hands until they are dry."

(b2)
On 02/14/18 at 10:AM, observations in the facility's Operating Room (OR) identified that Staff G (Certified Nursing Assistant) failed to remove gloves when switching from a contaminated to a clean task during the following:

After cleaning the OR table straps, Staff G disposed of the cleaning wipes into the garbage and used her gloved hands to push the garbage down. Staff G failed to remove the contaminated gloves and proceeded to pick up the wrapped table drape, remove the plastic packaging, disposed of the plastic packaging into the garbage, again pushing the garbage down with gloved hands and failed to remove her gloves. Staff G then placed the clean drape over the clean OR table with the contaminated gloves still donned.

After cleaning the OR table cushions, Staff G placed the contaminated cleaning wipes onto the clean OR table. Staff G then picked up the contaminated wipes, used the same wipes to clean the cataract machine, then placed the contaminated wipes onto the clean OR table again, failed to remove her contaminated gloves, then proceeded to place the plastic cover over the cataract machine.

These observations were confirmed with Staff P (Senior Director of Peri-Operative Services) at the time of observation, who stated: "Yes, she [Staff G] should have changed her gloves on at least four (4) occasions that I saw."

The facility Policy and Procedure titled "Administrative: Hand Hygiene Guidelines", last revised 07/28/15 stated: "Gloves should also be changed any time the healthcare worker switches from contaminated to clean tasks."


FINDINGS RELATED TO (c) INCLUDE:

(c1)
Observations of the facility's M 4 Unit on 02/13/18 during a tour between 11:30AM and 12:30PM identified the following:

Staff D (Patient Care Technician) was observed performing glucose testing on Candida Auris Patient #7. The staff member removed her PPE after testing the patient, then walked across the Isolation Room to retrieve the glucometer from the patient's bedside without redonning a gown.

During an interview of Staff C (Nurse Manager) at the time of these observations, the staff member acknowledged the staff member (Staff D) should have donned a gown prior to retrieving glucometer.

The facility Policy and Procedure titled "Candida Auris-Infection Control Recommendations for Infected or Colonized Patients" last revised 08/13/2017, contained the following statement: "Healthcare personnel should still use gowns and gloves when performing tasks that put them at higher risk of contaminating their hands or clothing."

(c2)
During a tour of the Central Sterile Service on 02/14/18 between 10:30AM and 11:45AM, Staff T (Central Supply Aide) was observed in the Decontamination Room without a mask and beard cover as required. This was confirmed with Staff R (Patient Care Director) and Staff S (Central Services Manager) at the time of the observation.

Per interview with Staff S, all staff with facial hair are required to wear a mask and beard cover.

The facility Policy and Procedure titled "Decontamination-Receiving and Handling", last revised 06/2015, stated: "Dress code.... The staff working in this decontamination area shall wear ... masks ..."


FINDINGS RELATED TO (d) INCLUDE:

Observations in the facility's OR of Staff G (Certified Nursing Assistant) and Staff H (Anesthesia Technician) on 02/14/18 between 10:30AM and 11:00AM identified that Staff Members G and H failed to move equipment to allow mopping of the floor surfaces underneath. The anesthesia cart and anesthesia machine were not moved and instead, mopping was performed around the equipment.

The facility Policy and Procedure titled "Cleaning Operating Room Suites Between Cases", last revised 11/20/17, stated: "The operating table and other equipment shall be moved to allow retrieval of all debris under them and mopping of the floor surfaces."

Per interview of Staff P (Senior Director of Peri-Operative Services) at the time of observation, Staff P confirmed the findings and added: "CNAs are not allowed to touch the anesthesia equipment and the Anesthesia Technician may not be present in the room while the CNA staff is mopping to move the equipment for them. But, the equipment should be moved for mopping."


FINDINGS RELATED TO (e) INCLUDE:

During a tour of the Central Sterile Service on 02/14/18 between 10:30AM and 11:45AM, with Staff R (Patient Care Director) and Staff S (Central Service Manager), four (4) unsecured Sharps Containers were observed on the floor in the Decontamination Room.

Per interview with Staff S, Sharps Containers are picked up once a week by an outside Vendor and he was not aware that they were supposed to be secured.

During a tour of the Endoscopy Suite on 02/14/18 between 2:00PM and 3:00PM with Staff R and Staff U (Assistant Head Nurse), two (2) unsecured Sharps Containers were observed on the floor in the Endoscopy Procedure Room, and one (1) unsecured Sharps Container was observed on the floor in the Bronchoscopy Procedure Room.

Per interview with Staff Dd (Director of Environmental Services) on 02/14/18 between 3:00PM and 3:45PM, the Director stated that "Sharps Containers are managed by an outside Vendor, and that the facility did not have a Policy for securing the Sharps Containers."

The facility's Contract with Stericycle (the Contracted Vendor) dated 10/18/17 stated that: "All special function items including ... Brackets and Floor Dollies, [for the securement of sharps containers] will be supplied by Stericycle at the time of initial installation."